Notable, an emerging digital health startup in voice-powered healthcare has launched the first wearable voice-powered smart assistant for physicians that will transform the healthcare experience. Available as a white labeled solution for wearables, the platform leverages artificial intelligence and voice recognition technology to automate and structure every physician-patient interaction as well as eliminate the vast majority of clinical administrative work. The Notable team consists of technology industry veterans. To date, Notable has closed an initial $3M round of seed funding led by Greylock Partners, with additional participation from Maverick Ventures and 8VC.

The amount of time physicians spend on paperwork and administrative tasks continues to increase with most spending more than 10 hours per week. While EHRs have digitized health records, the overhead of data collection often leads to patient data that is sparse and lacks information. These systemic challenges burden patient care with overhead and inefficiency, and lead to physician burnout as time is increasingly spent behind a computer instead of on patient care.

Notable is the first ever voice-driven medical assistant app built for the Apple Watch. It utilizes voice wake features that make it possible for clinicians to complete an encounter with just one tap. Notable automatically structures conversations, dictations, orders, and recommends the appropriate billing codes. Data is automatically entered into the EHR in a secure manner using robotic process automation. Since its beta launch, Notable has greater than a 98.5 percent approval rate, saves physicians at least an hour per day, and is already powering thousands of visits per month in multiple specialties.

Notable, an emerging digital health startup in voice-powered healthcare has launched the first wearable voice-powered smart assistant for physicians that will transform the healthcare experience. Available as a white labeled solution for wearables, the platform leverages artificial intelligence and voice recognition technology to automate and structure every physician-patient interaction as well as eliminate the vast majority of clinical administrative work. The Notable team consists of technology industry veterans. To date, Notable has closed an initial $3M round of seed funding led by Greylock Partners, with additional participation from Maverick Ventures and 8VC.

The amount of time physicians spend on paperwork and administrative tasks continues to increase with most spending more than 10 hours per week. While EHRs have digitized health records, the overhead of data collection often leads to patient data that is sparse and lacks information. These systemic challenges burden patient care with overhead and inefficiency, and lead to physician burnout as time is increasingly spent behind a computer instead of on patient care.

Notable is the first ever voice-driven medical assistant app built for the Apple Watch. It utilizes voice wake features that make it possible for clinicians to complete an encounter with just one tap. Notable automatically structures conversations, dictations, orders, and recommends the appropriate billing codes. Data is automatically entered into the EHR in a secure manner using robotic process automation. Since its beta launch, Notable has greater than a 98.5 percent approval rate, saves physicians at least an hour per day, and is already powering thousands of visits per month in multiple specialties.

“We see massive opportunity in Notable and the work they are doing to fundamentally change the physician-patient experience,” said Jerry Chen, partner at Greylock Partners. “The Notable team’s expertise in building products in highly regulated industries gives them an unparalleled advantage, enabling them to create the first voice-powered application and solve a true problem for physicians.”

Is it time to go a new route with your EHR system? Before you decide yes or no, weigh the positives and negatives.

Only 34 percent of physicians are satisfied or very satisfied with their EHR systems, according to a recent survey conducted by the American Medical Association and AmericanEHR Partners. Another survey published in the American Academy of Family Physicians' journal, Family Practice Management reported that only 39 percent of respondents who changed EHRs were pleased with their new system.

The results of these surveys outline how the decision to change EHR systems or not is a difficult one. After all, it's a significant financial investment and staff have spent a lot of time learning how to implement and use their system. If you change, your practice will have to foot these costs all over again. In addition, you face the potential loss of data and problems with data migration.

HANG IN THERE

"A well-designed EHR should be physician centric, specialty specific, and serve as a tool for the physician to document a patient's visit," says John Pitsikoulis, managing director of Berkeley Research Group, LLC, a firm located in Hunt Valley, Md. "The EHR must also meet the practice's business needs, including the revenue cycle. When an EHR doesn't align with a practice's specific day-to-day work flows, it makes the physician's job more difficult by increasing [his] administrative and compliance workload. By negatively impacting the physicians' time, patient care is impacted."

While it's tempting to want to replace something that doesn't meet your expectations, under certain circumstances you may want to give it more time. "First, determine if your current system offers enough functionality for managing your practice and achieves meaningful use requirements set forth by CMS. Also, verify that the vendor's strategy for future enhancements outweigh any short-term disadvantages," Pitsikoulis advises.

If your practice likes some of the core features and functions of the system, already developed specialty-specific templates, and can live with navigating through notes, orders, and prescribing without overwhelming frustration, living with the current system makes sense at least for the short term, Pitsikoulis continues.

One common complaint of physicians is that they have become data entry clerks at the expense of patient care. "This is a common physician finding, regardless of the EHR system," Pitsikoulis says. "But changing systems could result in the same functionality."

The truth of the matter is that a lot of systems aren't lacking in functionality and can be beneficial if you take the time to learn how to use them, says Eagan, Minn.-based Derek Kosiorek, principal consultant of Medical Group Management Association (MGMA) Healthcare Consulting Group. One way to determine if this is the case at your practice is by finding out which physicians successfully use the EHR. If it's more than half, then the EHR isn't the problem and other doctors need to invest more time in learning to use the system more efficiently. See if those doctors can assist others in learning the system.

TROUBLESHOOTING

Before throwing in the towel, see if the vendor is willing to work with you on resolving issues. Work with the vendor to identify each problem and then ask if the vendor can offer a solution, says Mechanicsburg, Pa.-based David J. Zetter, founder and consultant at Zetter HealthCare.

If it is more difficult to order tests or enter information into the medical record than before having the EHR, something is wrong, says Ann Arbor, Mich.-based Joette Derricks, owner of Derricks Consulting, LLC. The EHR should streamline the work flow, not add more steps. If employees are printing out information and still depending on paper, something is probably not set up properly. Open communication is critical to identify and resolve problems.

Making some enhancements to the EHR documenting process with voice recognition software, streamlining the physician coding function with built-in coding software, and optimizing the EHR features and functions with templates, could provide some shortcuts that make an EHR more desirable, Pitsikoulis says.

However, be cautious when adding these enhancements. Engage consultants with operational, technical, and coding compliance expertise to integrate the physician's work flow with the technology. "Otherwise, you might end up with similar performance dissatisfaction with the next tool," Pitsikoulis says.

PULL THE PLUG

Sometimes, despite your best efforts, you may want to call it quits. Poor technical support is a key reason to get a new vendor. "Oftentimes, marketing staff is very accessible early on and then a year after implementation you can't get a basic question answered," Derricks says. In this instance, it's time to move on.

Furthermore, if the vendor does not update its software to facilitate new medical technology or contractual payment updates, that's problematic, Derricks says.

In addition, if an EHR lacks the ability to integrate with other software such as laboratory tests, diagnostic tests, practice management systems, and so forth, it's probably time to start anew, adds Zetter. Other reasons to say "adios" are if staff cannot effectively use the system, if it impedes patient care, or if it's just too costly to continue to use.

Or, if information is consistently incorrect because the system is set up poorly, or you're finding bad data, start over, Kosiorek says.

MAKING A DECISION

Even though EHRs may pose a lot of challenges, their ability to exchange health information electronically has enormous benefits. EHR capabilities, such as electronic prescribing, improve patient and provider communication, while providing for the patient.

If you're unhappy with your EHR, it's important to understand what went wrong in your last EHR selection so you don't repeat those mistakes. Perform a needs assessment by categorizing the current deficiencies and determine if these can be improved. If not, then it's time to begin the process of selecting a better EHR.

CHOOSE RIGHT THE FIRST TIME

After incorporating a new EHR system, many physicians will have to change the way they've done their job since beginning their careers. "They are being asked to take information in their paper chart, shuffle it like a deck of cards, and then have it presented to them in various places on a computer screen," says Eagan, Minn.-based Derek Kosiorek, principal consultant of the Medical Group Management Association Healthcare Consulting Group. "Then, they have to get used to navigating to where the information is relocated. This can be difficult, as some vendors in the early days of creating EHR software didn't design it in the most user-friendly way for physicians."

Fortunately, this is evolving, but as a result it's leaving some physicians wondering whether to stick with the old or upgrade to something new.

Whether selecting an EHR for the first, second, or third time, the selection, implementation, and integration of work flow with new technology is complex, and requires continuous process improvement. "Usually, the need to make a decision and begin the implementation process gets in the way of a complete and thorough understanding of the technology and the practice's needs," says John Pitsikoulis, managing director of Berkeley Research Group, LLC.

When beginning the process of selecting an EHR, a practice's providers and staff should have an opportunity to "kick the tires." Yet, very few often do, says David J. Zetter, founder and consultant at Zetter HealthCare. Trying out a potential system gives users a chance to determine if it's a good fit. For example, they should ask the vendor "How will the EHR work with the practice's way of documenting a patient encounter? How will the practice management part of the software suite work? And, what is the reporting like?" And to make sure that the EHR will fit your unique needs, talk to other same-specialty practices that use the same system.

In addition, practices often fail to thoroughly check references. "Don't accept only a few names as references," Zetter says. "Ask proper questions of many practices that have implemented it, such as 'Would they choose it again? Why or why not?'"

Earlier this week, Andy Slavitt, Acting Administrator for CMS, told a group of attendees at the J.P. Morgan Annual Health Care Conference that meaningful use is on its way out.

“Now that we effectively have technology into virtually every place care is provided, we are now in the process of ending meaningful use and moving to a new regime culminating with the [Medicare Access and CHIP Reauthorization Act of 2015] (MACRA) implementation,” Slavitt told attendees. “The meaningful use program as it has existed, will now be effectively over and replaced with something better.”

The idea that meaningful use, a program which began in 2011 and aimed to incentivize or penalize physicians for adopting an EHR system, would be over, naturally caused many physicians to celebrate. Melissa Young, an endocrinologist in Freehold, N.J., and a member of the Physicians Practice Editorial Board, e-mailed a three word reaction to the news: “Hooray! ‘Nuff said.”

The AMA had a more formal way of celebrating this news. Of Slavitt, AMA President and CEO, Steven Stack, an emergency physician, told Beckers Hospitals Review in a statement: "He listened to working physicians who said the meaningful use program made them choose between following Byzantine technological requirements and spending more time with their patients. This is a win for patients, physicians and common sense."

In his speech, Slavitt talked about winning the “hearts and minds” of physicians back. Getting rid of meaningful use would undoubtedly help the federal agency achieve that goal, as evidenced by the rising number of docs who opted out of the program due to its stringent requirements. “The concept of meaningful use was always doomed to failure and it has been proven that there is no improvement in the quality of our healthcare delivery system and it has not reduced the costs of the provision of medical care,” Jeffrey Blank, a podiatric physician in Loxahatchee, Fla., and a member of the Physicians Practice Editorial Board, said via email.

Hold that Thought

Despite the excitement, Robert Tennant, health information technology policy director for the Medical Group Management Association (MGMA), says physicians should keep the champagne on ice. For one thing, they will still be judged on EHR and technical capability.

At the conference, Slavitt talked about MACRA, which authorized the creation of the Merit-Based Incentive Payment System (MIPS). MIPS will measure and compensate physicians on quality, practice improvement, cost, and use of technology. Within MIPS will be elements of meaningful use. Rather than rewarding physicians for using technology, MIPS will aim to pay them on using it towards improving their outcomes.

While Tennant says a reworked meaningful use is “potentially very positive,” the guidelines for MIPS are supposed to be released and finalized this year, which he notes could be a problem for physicians. “Payment under MIPS is supposed to take effect in 2019. If the traditional approach of using a two-year look back [to make those adjustments] is in place, it would mean reporting would begin in 2017,” he says. “If you look at the timing from a regulatory process, we’re concerned with how this would be accomplished.”

In essence, vendors would have to redevelop software around the guidelines, train customers, and practices would have to go live within the space of a year. Moreover, Tennant says if MIPS regulations are finalized in December of this year, they’d likely overlap with a new presidential administration.

“Any new administration, the first thing they do is typically put all pending regulations on hold and review them before they approve,” he says. Tennant also notes practices still have to be concerned over meaningful use regulations for 2016, including a full-year reporting period and the fact that Stage 3 of meaningful use is technically supposed to be mandatory in 2018.

“We don’t know what we are moving ahead to,” Tennant says. For practices, he advises to select software that fits their clinical needs and to not worry about “arbitrary and potentially changing” regulations. “Don’t focus on 2017 or beyond. We don’t know. The vendor doesn’t know.”

Even still, he is “cautiously optimistic” about Slavitt’s remarks. “We’re hoping CMS takes this opportunity to leverage MACRA to develop a program that is achievable and clinically relevant,” he says.

Blank is interested to see what lies ahead with government regulations, but is not as optimistic as Tennant. “I'm sure that many interest groups and the insurance industry will profit and doctors like me will continue to struggle,” he says.

Just 10 percent of Texas physicians are confident that their practice is prepared to transition to ICD-10 on Oct. 1, according to a new survey from the Texas Medical Association (TMA).

In July of 2015, Texas physicians were surveyed regarding their practice’s readiness to transition to ICD-10. Approximately 37,000 Texas Medical Association members and non-members with email addresses in the TMA database were emailed a link to the survey. The results are based on 936 responses. According to TMA, 97 percent of respondents currently treat patients in active medical practice. Among physicians who quit treating patients in active medical practice, 48 percent quit due to regulatory and/or administrative burdens and 22 percent quit due to ICD-10.

Nearly two-thirds (65 percent) of all physicians responding have little or no confidence that their practice is prepared to transition to ICD-10 by the deadline, even though the new coding system is supposed to enable doctors’ offices to collect and report more detailed patient data. “It’s horrible,” TMA President Tom Garcia, M.D., said in a statement. “The United States is the only country that couples the ICD coding with payment. The implications are that the doctor/patient relationship is going to be stressed.”

The survey found that few physicians have begun transitioning to ICD-10 extensively (7 percent). Physicians employed in hospitals are least likely to feel their practice has begun to transition to ICD- 10 extensively (3 percent). Even among physicians who feel very confident their practice is prepared to transition to ICD-10, only 42 percent report their practice has begun transitioning extensively.

Regarding training, 53 percent of physicians report the staff, and 46 percent report the physicians in their practice have taken ICD-10 preparation courses or training. Physicians in partnerships (34 percent) and the staff of solo practices (39 percent) are least likely to have taken preparation courses or training in ICD-10.

What’s more, older physicians are more likely to close or sell a practice and/or retire early in response to delayed or denied claims payments as a result of ICD-10. Physicians in the youngest age group (40 years and younger) are more likely to terminate or renegotiate plan contracts (34 percent).

Regarding electronic health record (EHR) status, 74 percent of physician respondents said that their practice currently uses an EHR. Among EHR users: 65 percent report their EHR is currently capable of handling ICD-10 codes; 29 percent of physicians whose EHR is not currently capable of handling ICD-10 codes are expecting an update; 15 percent of physicians report their will be a median cost of $10,000 associated with this update; and 1 percent of physicians report their software will need to be replaced.

The survey found that physicians fear the massive switch to the new coding system will disrupt patient care, and delay payment. In fact 83 percent of the doctors anticipate delayed or denied claims because of the transition, regardless of specialty. More than one-third of the physicians expect disruption so bad they will have to draw from personal funds to keep their practice open (36 percent) and almost one-third (30 percent) might retire early over anticipated cash-flow problems. (Almost half of the doctors age 61 or older might retire early.) Nearly a third (32 percent) might cut employees or reduce employee work hours or benefits.

Responding to the industry’s pleading, Medicare has said it will not deny doctors’ claims for one year whose ICD-10 codes are not specific enough, as long as the doctor submits an ICD-10 code from the correct family of codes. And if the doctor submits claims in the correct code family but are not specific enough, Medicare also will not audit those. Dr. Garcia said, “I asked for two years’ grace period but they only gave us a one year grace. I think it is going to take at least three years before this thing is finally settled down.”

The Department of Defense is about to move forward with its multi-billion dollar plan to overhaul its electronic health records system. But when you're an organization such as DoD, supporting 9.5 million active and retired military personnel and their beneficiaries, there are variety of important privacy and security challenges that must be prioritized and tackled, privacy and security experts caution.

In late July, the DoD awarded a $4.3 billion, 10-year contract to Leidos Partnership for Defense Health, a group of three main vendors that include EHR provider Cerner and consulting firms Accenture and Leidos Inc. The contract, which has the potential to be worth $9 billion if DoD exercises all its options over 18 years, involves the Leidos Partnership team transitioning the Pentagon's existing proprietary EHR system onto a Cerner off-the-shelf EHR at about 1,000 DoD sites worldwide, including military hospitals in the U.S., as well as health clinics in remote places such as Afghanistan.

However, as the Leidos partnership embarks on the massive overhaul, there are several critical privacy and security issues that need to be addressed to safeguard patient data throughout the plan.

Additionally, many of the challenges faced by the DoD in its EHR project are also similar - but much larger in scope - to the privacy and security concerns that healthcare organizations in the private sector face when undertaking their own EHR system migrations.

Those issues range from protecting patient data as its moved from one platform to the next, to thoroughly vetting the consultants involved with the EHR work.

Migrating Data

"Several security and privacy challenges exist as the DoD transitions from its old EHR to the new system," says Keith Fricke, principal consultant at consulting firm, tw-Security.

"Migrating from one EHR to another often involves importing historical data from the old system to the new one. The data set may be rather large," he notes. "Extracting data from the old EHR will likely result in a large interim database or data file. The database may need to be sent to the new vendor for data field mapping or importing."

Yet, it is not practical to send data extracts this large over a data connection. "Instead, it is better to send the data sets on an encrypted external hard drive, tracked via shipping provider," he says.

Data integrity issues are among the biggest challenges involved with such massive EHR undertakings, says Tom Walsh, founder of tw-Security. "Often times, the data mapping between an old system and new systems misses something. The only thing worse than no patient data is the wrong patient data."

To counter those problems, the data extraction process must include mechanisms to validate the data ultimately imported into the new EHR exactly matches the data stored in the old EHR, Fricke advises.

Another factor that needs close oversight is ensuring that role-based access controls to patient data are maintained from the old system to the new, especially where highly sensitive information, such as behavioral health data, is involved, Fricke says.

Privacy and security expert Kate Borten, founder of consulting firm The Marblehead Group, says it's equally important to ensure that the consultants working with or accessing the sensitive data are scrutinized. "I expect that many contractors will have access to PHI throughout this major project," she says. "It is very important that they be thoroughly vetted, that they be given the minimum necessary access permissions, and that they be monitored."

Long Haul

Because the DoD project will last several years, it's important to have measures in place to safeguard data during the various project stages.

"Workers should use simulated PHI rather than actual PHI as much as possible," Borten says. "Too often, PHI access is granted for development, testing, and training purposes, when simulated PHI could and should be used instead."

However, often a test environment must have real patient data in order to perform a true functional test, Walsh notes. "Security controls for test environments can often be less stringent. People using the test environment may forget that the data they are working with represents a real patient. Generic user accounts with easy to remember

passwords may be set up to help facilitate functional testing."

So, to avoid possible breaches or unauthorized access to PHI, the test environment needs to have security controls set to the same level as the production environment, Walsh recommends.

Because there will be thousands of people involved with the project - including individuals working for contractors and subcontractors - another danger is a watering down of security measures and practices that should be in place throughout the project, at all locations, for all personnel involved with the work.

"A front line worker may honestly say, 'I didn't know,' and it is a true statement," Walsh says. "Privacy and security education must be conducted for everyone involved."

As for securing data during project stages, Fricke recommends that data be stored on servers located in a secure data center and accessed via virtual desktops. "Doing so significantly reduces the likelihood that data is being stored on contractors' laptops or hard drives of workstations," he says.

"If storing data locally on laptops and desktops is required, these devices must be usingencryption."

User Access

In addition, Fricke suggests that two-factor authentication be used for any remote access to the data being worked on for the migration. "We've seen news stories in the past year about foreign countries targeting US government systems for hacking and exfiltration of data," he says. "The vendors involved in this EHR migration must ensure that all systems involved in the process have proper security patching levels, well-maintained malware protection, and 24x7 audit log monitoring."

Also, if any of the individuals working on this project had their information compromised in the Office of Personnel Management breach, extra care must be exercised to avoid becoming a victim of a spear-phishing attacks.

Because the DoD EHR systems contain healthcare data for U.S. military personnel, then the information potentially could be a hot target of the most devious cyberattackers, Walsh notes.

"The data in these systems are not just any patient. This is the patient data of the men and women who willing chose to serve our country," he says. "Our military personnel are prime targets for domestic and foreign terrorists. Workforce clearance will have to be strongly enforced for anyone involved, but especially far more rigid for any person with elevated privileges, such as system administrator, super user, etc."

Finally, because the DoD project will last at least a decade, maybe two, it's vital that all project work is thoroughly documented, Fricke says.

"It is important that from a project management perspective, the project managers ensure all project documentation is kept very current," he says. "There is always staffing turnover of project managers and contractors in a project this large and with the long timelines expected. Gaps in documentation will cause potential delays, potential rework and possible lapses in security practices as turnover occurs."

Only time will tell whether the endorsement by the American Academy of Family Physicians (AAFP) of a particular EHR technology will translate into increased EHR adoption among these providers.

Late last week, AAFP struck an agreement with EHR company, HealthFusion, to promote its MediTouch EHR technology among its members.

"MediTouch offers the specifications AAFP members need," HealthFusion Chairman Sol Lizerbram, RPH, DO, said in a public statement. "The system was founded and created by family physicians with the goal of enhancing the practice of medicine and improving provider workflows. The quality of the system has been recognized by numerous organizations and health systems. We are honored that we now have the opportunity to associate with AAFP and its membership."

According to the EHR vendor, its EHR technology is a means for family physicians to keep pace with federal regulation and industry standards for health IT use:

Family Medicine is finally being recognized for its critical contribution to the healthcare delivery system and we expect the role of Family Physicians to become even more prominent in the coming years as the nation transitions to alternative payment models. With our easy to use interface that assists with government compliance programs such as Meaningful Use and PQRS and our NCQA Pre-Validated Patient Centered Medial Home module, the MediTouch system is already prepared to work closely with AAFP members to meet the challenges of our ever changing delivery system.

For its part, AAFP has said little about the agreement. Its website includes details about HealthFusion/MediTouch EHR and practice management technology as part of discounts and services to members, with the following preface: "Help lower everyday practice costs and save time doing it. AAFP has done the research for you and negotiated the deal."

As for EHR adoption and use, AAFP has remained largely supportive of the EHR Incentive Programs, most recently in welcoming changes to meaningful use requirements proposed by the Centers for Medicare & Medicaid Services (CMS) earlier this year (although still awaiting finalization).

"Family physicians are among the earliest adopters of certified electronic health record technology and remain committed to the promise of delivering better health care with interoperable electronic health records," the organization said in February. "As health providers across the United States build out the EHR infrastructure over the coming years, family medicine will continue to play a central role, and CMS's announcement demonstrates that it is listening to our concerns. We’re gratified to see that our collective voice has been heard and needed change is coming."

As for billing and claims management, AAFP joined its voice with those of other provider associations in supporting additional ICD-10 flexibilities following the ICD-10 compliance deadline set for October 1.

The agreement between AAFP and HealthFusion is no guarantee of increased EHR adoption of a particular technology, but it does steer family physicians in an obvious direction when considering a specific health IT platform.

As smartphones and tablets become more accessible to consumers, and as their capabilities expand, nearly every industry is incorporating mobile technology into their business models. Banks, for instance, are creating apps to help customers monitor their finances from mobile devices, retailers are rushing to make their websites "mobile-friendly," and schools are budgeting to add tablets to classrooms.

Healthcare should be no exception, but surveys indicate that many practices and physicians are lagging when it comes to fully utilizing mobile devices in patient care. While most physicians are using mobile devices such as smartphones and tablets, at work, according to our 2014 Technology Survey, Sponsored by Kareo, few are using them to assist with direct patient care. For instance, the majority said they use their mobile devices to look up drug information, read journal articles, and access CME opportunities, but only 10 percent said they are using them to remotely monitor patients' health information, such as their vital signs.

Still, family physician Linda Girgis, who is on the advisory board for physician social networking site SERMO, predicts that physician use of mobile devices in patient care will pick up traction. More and more physicians on SERMO, Girgis says, are beginning to participate in discussions about mHealth, ask questions, and share ideas. "We're talking about it more and it's something that more are going to be incorporating into their practice," she says.

Jonathan Linkous, CEO of the American Telemedicine Association, agrees that use of mobile devices in patient care is gaining momentum. One reason is that the administration of healthcare through a mobile device does not cost a lot of money for patients and physicians, as mobile devices are something that most are already using anyway. "A mobile device is not necessarily a healthcare device, it can be anything that people use for communicating, and then it can also be used for healthcare, and that's why it's been very useful," says Linkous. "You're not always having to invent new technology, or always having to invent new ways of connecting people, you're just adding on to technology that's already been deployed."

Another factor leading to mHealth popularity is that more patients are expressing interest in it, says Linkous. You may already be experiencing this in your practice. "... I think they're coming to the doctor and asking them, 'I have a heart condition,' 'I have high blood pressure,' 'I have —whatever else it might be — are there any applications on the cell phone I can use?' And so now the doctors are being asked questions by their patients about what applications can I download, or what types of devices can I use to help me take better care of myself."

As the ICD-10 implementation deadline drew closer, more lawmakers began attempting to develop a different type of transition period in which healthcare providers would not be penalized for reporting inaccurate ICD-10 codes. For example, HR 2247, the ICD-TEN Act, would create a “safe harbor” for providers in which they wouldn’t be denied reimbursement “due solely to the use of an unspecified or inaccurate sub-code.”

The Coalition for ICD-10 states that the Centers for Medicare & Medicaid Services (CMS) has often accepted less specific codes under ICD-9 and, when the ICD-10 implementation deadline hits, the new reporting requirements will have no difference in level of specificity.

“CMS has reiterated numerous times that their acceptance of unspecified codes will not change as a result of the ICD-10 transition,” the Coalition for ICD-10 explains. “Furthermore, it would be inappropriate and a violation of coding rules to require a level of specificity that is not documented in the medical record. Indeed, CMS has made it abundantly clear that it would be inappropriate to select a specific code that is not supported by the medical record documentation or to conduct medically unnecessary diagnostic testing in order to determine a more specific code.”

Essentially, the ICD-TEN Act was proposed due to physician fears that there may be a significant increase in the number of claim denials once the ICD-10 implementation deadline takes effect.

However, the latest CMS end-to-end testing results show that there is only a 2 percent denial rate of claims due to ICD-10 errors. This shows that the physician fears may be unfounded.

According to the Coalition for ICD-10, a “safe harbor” transition period is not necessary and the current status of the ICD-10 implementation deadline should take effect on October 1 as is.

Additionally, CMS released its acknowledgement testing results taking place between June 1 and June 5. CMS accepted a total of 90 percent of claims submitted across the nation during this time period.

While a 10 percent denial rate is significant, CMS holds that the majority of claim rejections were due to submission errors within the testing environment that won’t affect the processing of claims when real claims are submitted after the ICD-10 implementation deadline.

It is time for providers to be ready for the ICD-10 implementation deadline or else risk having their claims rejected once October 1 hits. Any provider who submits ICD-9 codes after the deadline risks having the claims returned to their facility, returned as unprocessable, or rejected, according to apamphlet from CMS.

“As we look ahead to the implementation date of ICD-10 on October 1, 2015, we will continue our close communication with the Centers for Medicare and Medicaid Services to ensure that the deadline can successfully be met by stakeholders,” House Energy and Commerce Committee Chairman Fred Upton (R-MI) and House Rules Committee Chairman Pete Sessions (R-TX) stated at the end of 2014. ““This is an important milestone in the future of health care technologies, and it is essential that we understand the state of preparedness at CMS.”

With less than three months remaining until the nation switches from ICD-9 to ICD-10 coding for medical diagnoses and inpatient hospital procedures, The Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA) are announcing efforts to continue to help physicians get ready ahead of the October 1deadline. In response to requests from the provider community, CMS is releasing additional guidance that will allow for flexibility in the claims auditing and quality reporting process as the medical community gains experience using the new ICD- 10 code set.

Recognizing that health care providers need help with the transition, CMS and AMA are working to make sure physicians and other providers are ready ahead of the transition to ICD-10 that will happen on October 1. Reaching out to health care providers all across the country, CMS and AMA will in parallel be educating providers through webinars, on-site training, educational articles and national provider calls to help physicians and other health care providers learn about the updated codes and prepare for the transition.

“As we work to modernize our nation’s health care infrastructure, the coming implementation of ICD-10 will set the stage for better identification of illness and earlier warning signs of epidemics, such as Ebola or flu pandemics.” said Andy Slavitt, Acting Administrator of the Centers for Medicare and Medicaid Services. “With easy to use tools, a new ICD-10 Ombudsman, and added flexibility in our claims audit and quality reporting process, CMS is committed to working with the physician community to work through this transition.”

“ICD 10 implementation is set to begin on October 1, and it is imperative that physician practices take steps beforehand to be ready,” said AMA President Steven J. Stack, MD. “We appreciate that CMS is adopting policies to ease the transition to ICD-10 in response to physicians’ concerns that inadvertent coding errors or system glitches during the transition to ICD-10 may result in audits, claims denials, and penalties under various Medicare reporting programs. The actions CMS is initiating today can help to mitigate potential problems. We will continue to work with the administration in the weeks and months ahead to make sure the transition is as smooth as possible.”

The International Classification of Diseases, or ICD, is used to standardize codes for medical conditions and procedures. The medical codes America uses for diagnosis and billing have not been updated in more than 35 years and contain outdated, obsolete terms.

The use of ICD-10 should advance public health research and emergency response through detection of disease outbreaks and adverse drug events, as well as support innovative payment models that drive quality of care.

CMS’ free help includes the “Road to 10” aimed specifically at smaller physician practices with primers for clinical documentation, clinical scenarios, and other specialty-specific resources to help with implementation. CMS has also released provider training videos that offer helpful ICD-10 implementation tips.

The AMA also has a broad range of materials available to help physicians prepare for theOctober 1 deadline. To learn more and stay apprised on developments, visit AMA Wire.

CMS also detailed its operating plans for the ICD-10 implementation. Upcoming milestones include:

Setting up an ICD-10 communications and coordination center, learning from best practices of other large technology implementations that will be in place to identify and resolve issues arising from the ICD-10 transition.

Sending a letter in July to all Medicare fee-for-service providers encouraging ICD-10 readiness and notifying them of these flexibilities.

Completing the final window of Medicare end-to-end testing for providers this July.

Offering ongoing Medicare acknowledgement testing for providers through September 30th.

Providing additional in-person training through the “Road to 10” for small physician practices.

Hosting an MLN Connects National Provider Call on August 27th.

In accordance with the coming transition, the Medicare claims processing systems will not have the capability to accept ICD-9 codes for dates of services after September 30, 2015, nor will they be able to accept claims for both ICD-9 and ICD-10 codes.

Also, at the request of the AMA, CMS will name a CMS ICD-10 Ombudsman to triage and answer questions about the submission of claims. The ICD-10 Ombudsman will be located at CMS’s ICD-10 Coordination Center.

Given the "epidemic of waste [that] blights the U.S. health care delivery system," investment in health care information technology systems is a no-brainer. After all, doesn't the magic wand of IT improve the efficiency of every industry it touches? Congress thought so, and, as a result, in 2009, it allocated $20.6 billion as part of the American Recovery and Reinvestment Act to encourage doctors and hospitals to adopt and use IT systems and migrate from their old paper records to the new electronic health record systems.

Meaningful Use program

To decide who qualifies for these generous incentives, the Department of Health and Human Services, through the Centers for Medicare & Medicaid Services, designed a set of criteria called meaningful use, a three-stage compliance program that requires providers show they're using electronic health records in measurable ways. To receive the financial incentives, doctors and hospitals must attest to reaching different stages of meaningful use.

The first stage of the program was designed to drive medical providers to adopt the records. As long as the government was willing to pick up the tab, doctors were willing to buy fancy electronic health record software and not worry about using it. Electronic health record vendors enjoyed an artificial market created by the billions of dollars of incentives included in the Recovery Act's Health Information Technology for Economic and Clinical Health Act. The majority of providers successfully attested to this first stage and as a result, record adoption rates skyrocketed.

Why the second stage failed

Now that everyone had electronic records, the next stage of the program had to logically focus on using this technology. Unsurprisingly, the second stage was not welcomed in the medical community. As of February 2015, roughly a quarter of physicians had complied with the requirements of this stage. Despite the lackluster results of the second stage of the program, HHS has already proposed the rulesfor the third stage, which is primarily focused on health information exchange among providers. While my own research documents huge benefits of exchanging health information, I believe that before implementing more complicated rules and regulations, we should have a clear understanding of the reasons for which the second stage of the program has failed. Without learning from the past, the future will not be brighter.

Although policymakers' hunch about the benefits of IT was correct, it failed to understand a nuanced condition under which this magic wand works: organic and voluntary adoption. Imposing these records on the medical community and forcing them to adopt and use this technology was destined to fail. Meaningful use is focused on adoption and use of electronic records as the final goal, which misses the whole point: that IT in health care, just like in any other industry, is a means to achieve the actual goal of efficiency. More importantly, meaningful use considers electronic health records as the only type of IT solution and ignores the fact that there are many other IT services that can help medical providers much more. The "one-size-fits-all approach," as American Medical Association President Steven Stack put it, of meaningful use ignores the differences between physicians and incorrectly assumes that medical care is mass-produced in the same way by all physicians and thus only one IT solution best addresses the unique needs of many different types of medical providers.

Policy recommendations

Meaningful use should have been integrated with the capitated payment models, in which the medical providers are paid a fixed amount per patient and are rather encouraged to provide the best care at the lowest cost. The need to cut costs and increase quality would have driven medical providers to adopt a wide variety of IT solutions that specifically address their unique needs. HHS should have set efficiency as a goal and let medical practices to find out the best way to achieve it through health care IT of their choosing. Instead of mandating physicians to record the smoking statuses and vital signs of all patients, send them reminders about their follow-up visits, and communicate with them through secure electronic messages, meaningful use incentives could have been allocated to fund a wide variety of different IT solutions suggested by medical providers.

Using a small part of the incentives now used for meaningful use compliance, we can run a pilot project and test this idea. HHS should call for proposals for IT projects that each provider, based on its own unique characteristics, deems the best way to cut costs and increase quality. Just like research grants, these proposals can then be evaluated by a panel of experts and funded only if approved. This approach will open up the market for meaningful and innovative IT solutions that actually help medical providers improve their efficiency.

Rather than being stuck with electronic health records as the only IT solution, we can have a national lab in which the performance of many different IT solutions will be tested. Medical providers will find their best way to be more efficient and will adopt the IT solutions that best fits their needs organically and voluntarily. Only then IT will work its magic in the health care sector.

Seeking to provide balanced discourse and to recognize marginalized voices at the gooey center of health care, I kindly ask that you find a seat in the Captain’s Room of the Hilltop Motor Lodge for the inaugural meeting of Physicians for the Liberty of the Electronic Health Record, where founder and president Dr. IM Klickhffor starts the proceedings with this plenary talk.

Thank you, thank you. Many of you are using this weekend to catch up on your charting. To raise your hands from the keyboard and clap so generously fills my heart with a JOY template. This weekend wouldn’t be possible without the generosity of the IT companies crowding the exhibit hall, the motel gym, and the less humid corners of the indoor pool. But any conflicts of interest on my part are entangled more with the contradictions that make us human.

Why are we here? I’d argue it’s because medicine is in desperate need of a new orderset, and it’s called EMRpathy. Physicians must value electronic medical records, EMRs, and the larger enterprise of electronic health records, because they possess intrinsic worth. This complex, vulnerable and sensitive software shouldn’t be tolerated for their financial incentives and then insulted for destroying the doctor-patient relationship.

We must stop treating the unexpected screen, dialogue box or pop-up menu as an uninvited guest and instead embrace the opportunity to be questioned by these beneficent and diligent systems. In this way, our colleagues might discover what we’ve known all along — the meaning at the heart of “meaningful use.”

But such radical ideas tug at the roots of precepts that anchor the medical profession, namely the Hippocratic writings. We’ve all been to medical school. We’re familiar with aphorisms such as, “it is more important to know the patient who has the disease than the disease the patient has.” I dare not contradict Hippocrates, but medicine has advanced over the past 2,500 years. An ICD-10 diagnostic code exists for the craziest stuff, like “Spacecraft crash injuring occupant, initial encounter,” but you won’t find a code for restoring the imbalance of the four humors.

No disrespect to Hippocrates, after all, he’s famously the father of western medicine. But when it comes to the challenges in our modern age, he risks appearing as a deadbeat dad.

The most important element in the care of our patients in 2015 is documentation. If we don’t represent the patient in the EMR, the patient doesn’t exist. If not documented appropriately, a skilled and expert physical exam never happened, and intimate conversations with a patient or family become figments of our imaginations. We don’t get paid if the coders can’t play the coding game, and where do they play that game — on the field of the EMR.

The EMR holds the heart, lungs and soul of medicine. In a better world, we wouldn’t need lobbyists to fight for EMRpathy, but my own story speaks to the challenges before us.

My personal journey almost ended at the login page. Ten hours of formal training outside of my hectic clinical schedule, followed by thirty hours on my own time practicing and cursing the system. Like you, I screamed in my sleep, woke up dripping in sweat. I went to a dark place, seriously chewed on the idea of a professional reboot out of clinical medicine, the profession I loved.

But during one ER shift, I asked the EMR representative why most EMRs seemed designed by medical students who graduated last in their class. Why couldn’t the EMR be more user-friendly, intuitive and ready to go out of the box? She listened with unflappable calm, blew a thread of chestnut hair that had drifted over her eye. “Let’s explore,” she said, beaming, and clicked through each busy screen like an astronomer canvassing a night sky. “Take a seat,” she said. “But before logging in, I want you to contemplate the important relationships in your life, your family, and close friends. Were they always smooth sailing? Of course not. If marriage requires work, why wouldn’t your relationship with the EMR, who you’ll be spending more time with than your wife, be any different?”

“But isn’t empathy with the user a fundamental principle of design thinking?” I said. “Because I don’t feel the love.”

“Didn’t Hippocrates say the patient comes first?” she said.

“But this system doesn’t put the patient first, either.”

“It puts their chart first,” she said. “If Hippocrates had to document on his patients, he wouldn’t have had time to write what he did.”

That revelation struck me in the head like a dropdown menu. Resentment won’t make the EMR better, only patience and EMRpathy. Imagine Hippocrates working as an ER physician in 2015. He would be stomping around the trauma room in clogs, grumbling and scratching under the collar of his scrub top. Why? His Press Ganey surveys were riddled with patient comments about his sandals and tunic.

Physicians complain about the utility of such patient satisfaction scores, especially when it’s tied to their reimbursement, and I must confess that I agree with them on this point. Does it make sense to evaluate and compensate physicians on our interactions with patients when medical practice is now about the Doctor-EMR relationship? Studies show that ER physicians spend twice as much time with the EMR than with their patients, and that’s high touch intimacy, with over 4,000 mouse clicks in a busy 10-hour shift. Who touches patients 4,000 times in a shift?

Physicians lament how EMRs keep them away from the bedside of their patients. But the bedside is vanishing, too. Through telemedicine, patients exist on the screen, not sitting on a stretcher before us. No bedside to sit at. Nobody to examine. And with no body to examine, we point to the physical exam, and it looks very different. Despite the evolving state of the clinical encounter — bedside or screen — our patients’ digital symptoms are seamlessly melded with orders and decision-making and preserved as one in the EMR.

Hippocrates still breathes, only it’s Hippocrates 2.0. We’re creating a digital life. Physicians must turn their gaze to the EMR with eyes wide open and appreciate the EMR as another respected colleague.

Corporations are considered people, so why not EMRs? The EMRpathy orderset asks physicians to be sensitive to the EMR’s feelings and point of view. Medical schools must recognize EMR disparities and develop curricula in EMR cultural competency. Reading literature that ventures beyond the people-centric canon would mark a solid first step in changing the culture. It will take time. But if we teach and champion effectively, the next generation of physicians won’t flinch at each honk and hard stop, or respond rudely to the dialogue boxes insisting on conversation. They’ll accept documentation as a quest. They’ll understand that our response to obstacles defines our character as individuals and physicians.

What can you do right now? Acknowledge our keyboard intimacy, that our fingertips know the personality of each key better than it ever recognized an enlarged spleen or an S3 heart sound. Tenderly welcome each click and greet each drop down menu as an invitation for friendship. Slow down and click. And click again. And click some more. Be present in the moment, these endless moments of great meaning.

I’m happy to take questions. But if you want to take the next ten minutes to catch up on the charts, honor them with my blessing.

Many physician practices are ill-prepared for ICD-10, and health systems must ensure the right tools are in the hands of those who need them most, according to Bill Reid, senior vice president of product management and partners at SCI Solutions.

"Hospitals risk unsuccessful transitions if physician offices in their communities aren't ready," Reid writes for ICD10Monitor.com. Recent studies show that many still are not, despite the Oct. 1 implementation deadline looming.

For instance, a survey unveiled by the eHealth Initiative earlier this month showed that of 271 providers, half said they have conducted test transactions using ICD-10 codes with payers and clearinghouses. Only 34 percent said they have completed internal testing, while 17 percent have completed external testing.

Eighty-eight percent of test claims were accepted during the Centers for Medicare & Medicaid's second round of ICD-10 testing in April.

There are tools that health systems can use to ensure their "healthcare brethren" are moving forward with ICD-10, according to Reid. A cloud-based business management tool can help create a "crosswalk" to convert the ICD-9 code used most often to ICD-10 equivalents. The business management tools help ensure incidents are coded correctly, he says.

"These electronic bridges help ... make it as easy as possible for community physicians to send in accurate orders and referrals, with the correct codes being used from the start of that workflow," Reid says.

One scenario where this works includes if a patient needs to be scheduled for a CT scan. While the patient is at the practice, staff can use the management tool to schedule the order and while doing so select the prognosis which the program will then autopopulate the correct ICD-9 and ICD-10 codes.

The Workgroup for Electronic Data Interchange has warned that unless all industry segments move forward with implementation of ICD-10, "there will be significant disruption on Oct. 1, 2015."

Tens years ago, electronic health records seemed like a luxury for medical practices, but today, making the leap to EHR is more of a necessity. Healthcare reform is changing the way the medical community does business and switching to digital records is part of the process. The first generation of EHR software was problematic and cumbersome, but the modern versions offer real advantages to both patients and staff. Consider four reasons it is past time to get EHR software.

1. Inefficient Audit Trails

Whether you are attesting for meaningful use incentives and Medicare payments or going through a routine accounting audit, proper EHR software makes the process that much cleaner. Without EHR, there is no possibility of getting federal incentives, but the auditing benefits do not stop there.

Electronic record systems automate everything from billing to scheduling to general accounting processes. This means more accurate billing with proper coding – with ICD-10 on the horizon, coding will only get more complex, too. When tax time comes around, you have all the documentation necessary to file effortlessly.

EHR opens the lines of communication with insurance companies and federal agencies. When filing a claim or facing a request for repayment, you have a digital record necessary to prove your case.

2. Poor Productivity

EHR software is critical to improving staff performance, as well as the patient’s view of the medical service. A national survey of doctors found that after implementing EHR:

The practice functioned more efficiently

They could improve staff and stakeholder recruiting

It fostered better patient relationships

The little things like not having to hand write notes or prescriptions add up to more time with patients.

EHR improves scheduling by linking appointments directly to patient records and creates communication shortcuts for labs and consultations. Essentially, the workflow of the practice was better with electronic health records.

3. Wasted Space

Physical record storage wastes space that could be used for more practical and revenue-generating purposes. With EHR, you eliminate the need for paper records, opening up that storage area for new exam rooms, imaging equipment or to add another specialty to the practice.

With EHR, physicians can access patient information remotely, as well, making telemedicine a practical option. A doctor is available to answer staff or patient questions whether standing in line at the grocery store or doing rounds at the hospital, because he or she can see the patient records outside of the central storage area. That type of flexibility translates to better patient service and care.

4. Excessive Operating Expenses

An EHR system adds to the bottom line. Paper-driven systems are labor intensive. With the implementation of electronic health records, the agency no longer needs to pay filing clerks to pull and store charts, for example. There is no need to purchase or maintain elaborate retention and retrieval systems.

Reduced transcription costs – physicians and staff do updates as they go instead of dictating notes to be transcribed later

Improved reimbursements due to more accurate coding and better documentation

Lower risk of medical errors due to missing chart information – with a paper chart critical information like allergies can be misfiled

Enhanced wellness care and patient education opportunities – this is especially critical with the new healthcare reform practices focusing on quality not quantity. Practices are not getting paid for services rendered anymore, but for better patient outcomes. This is a factor for patients with chronic illnesses like heart disease or diabetes.

What does EHR bring to the table? Efficiency, productivity, better patient care and cost savings – all essential for agency success.

Human lives depend on how well a healthcare organization manages its EHR integration of medical devices.

The assigned project manager spearheading numerous large health system enterprise-wise medical device integration programs for over a decade, I’ve learned an essential lesson about EHR integration of medical devices.

Data captured from thousands of heart monitors, ventilators, balloon pumps, and other bedside devices must be perfectly managed, seamlessly integrated, and standardized to each patient’s electronic health record (EHR) and then made accessible to multiple providers. Once synced properly across the care continuum, connected medical devices play a critical role in the transfer of near real-time, reliable data to EHRs that improve both the safety and quality of patient care.

Otherwise, failing to do so can prove fatal.

Lessons borne out of experience

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My role in bringing together clinicians, IT experts and device vendor representatives is to achieve that goal through flawless organization of precise integration methods and over-communication. Sharing information among these three teams is paramount to our success — that is, we’re managing vital data used by physicians and nurses as analytics in making life-changing medical decisions as quickly as possible.

Additionally, I have learned other valuable lessons about EHR integration of medical devices.

Start with a clean inventory list of biomedical devices and equipment planned for the device integration project. This list should comprise the number counts of all devices and supporting equipment including firmware versions and serial ports in addition to Ethernet gateway connections.

At the project’s onset evaluate and identify devices lacking the capability to integrate. Identify older firmware versions and research feasibility of cost to update as opposed to replacement.

Conduct walkthroughs on clinical rounds to determine data points for integration in order to identify network cabling and power needs. At that time, initiate engaging device vendors and setting clear deadlines and key parameters for the EHR integration.

Invite middleware vendors to an onsite visit to determine exactly how much hardware is needed to ensure connectivity with other devices. Also include them in weekly or biweekly team update meetings. They are oftentimes overlooked.

Be adaptable and versatile to make quick adjustments while also striving to deliver impeccable results. Since workflows are not usually established upfront, responsibilities get shuffled around and integration details quickly become overwhelming.

Find creative ways to facilitate communication among the different team members. For example, assign color-coded status levels — green, yellow and red — to flag a change in project progression to speed up problem resolution. When senior management tackles red status issues as a group, expect people to pay attention!

Organization translates to project acceleration

Finally, organization of every integration detail is imperative. Associated device hardware, such as installing mounting hardware and new monitors in each patient room, must be managed. Biomedical managers, hospital IT groups, and clinical administrators must work concurrently to coordinate every step. In my experience, managing all of these different teams is by far the most challenging aspect of device integration.

Our healthcare ecosystem is slowly but surely modernizing, and we must leverage our technologies every possible way to maximize delivery of patient care to improve outcomes and the patient-provider experience. Ultimately, the success of any enterprise-wide EHR integration of medical devices is founded on strong communication and organization in addition to data management.

If you're not happy with your EHR system, making a change is not easier said than done. Take some time to weigh the pros and cons before a making this big decision.

"The advantage of keeping a sub-par EHR is that you don't have to go through the arduous process of changing EHRs," says Wanda is also president of the American Academy of Family Physicians. "However, one of the biggest disadvantages of keeping an EHR you don't like is that it tells the staff that they're not worth the investment in a better solution. Don't avoid making a switch because of the effort involved or the money you've already spent."

The advantage of making a change is that you'll hopefully pick a system that's more compatible with your needs. "Because you have the experience of what doesn't work in your current system, you can look for one that works better for your needs,” says John Meigs, Jr., a family physician at Bibb Medical Associates in Centreville, Ala., who is president-elect of the AAFP.

Filer's organization ultimately decided to change EHRs because, "the software was an unmitigated disaster. It was an incredibly expensive and time-intensive project to undertake, but I'm absolutely glad we switched EHRs."

Meigs, who has supported the use of EHRs for more than 20 years, hasn't liked any of the EHRs he's used. "Our current system takes too many clicks to do basic things, and the data isn't displayed in a way that is useful for patient care," he says. "The advantage to sticking with the devil you know is just that — you know what issues, challenges, and hassles you have to face."

Why is it that patients are slow to take charge of their health records? Some articles suggest that management of health information should be a patient-driven initiative and the points that are used to propagate this idea are not without merit. However, the primary reason is a lack of a collaborative effort among patients and providers. It is the responsibility of healthcare professionals – who bear more accountability than ever – to make a concerted effort to drive this change. And, since the technology is available to support this effort, the first step for providers is to embrace their influential role in educating patients on the importance of managing life-long health and wellness.

A Culture of Connectivity:

The healthcare industry is becoming increasingly decentralized and engagement through health monitoring among patients and providers is more possible today than ever. In an article in the Wall Street Journal (“Staying Connected Is Crucial to Staying Healthy”), reporter Laura Landro interviewed Dr. Joseph Kvedar, vice president of Connected Health at Boston-based nonprofit health system Partners Healthcare, about the increasing decentralization of care, as well as the spread of health apps and trackers.

Dr. Kvedar confirmed how, in the new network-based model of healthcare, connectivity is critical to providing the highest level of care, by saying “the ideal way to keep you focused on improving your health is through connectivity and in-the-moment, contextual messaging – messages directed at your specific health needs at the moment you need them.” The result of greater connectivity is higher engagement, but providers must actively pursue initiatives centered around leveraging filtered, personal health data from patients. Health providers need to have an influential role in closing the loop of contextual messages by responding on priority, as demanded by the condition at hand.

A Culture of Convenience:

Platforms that monitor individual patients for ongoing prevention and large populations with multiple chronic conditions, while managing exceptions, can do so with greater coordination. This will also have a positive impact on internal operations by minimizing errors in data as it is exchanged through faster, more secure channels. In turn, this increases staff productivity, minimizes intervention and streamlines patient processing and the overall patient experience within and independent of the clinical environment.

New breakthroughs in technology have helped overcome the traditional challenges of interoperability, making diagnosis and ongoing care more convenient than ever. Portable devices and clingy fitness trackers have contributed to having health vitals available at your fingertips; data that has now become easy to upload and analyze on any platform for possible conditions. And, as a recent article in The Economist states, “…computing power is now being applied successfully in countless small ways, using smartphone and other diminutive devices, to make a big difference to the effectiveness of treatments,” (“Bedside Manners”).

A Culture of Change:

It is up to providers to facilitate this change in the culture, from one of episodic care to an ongoing healthy lifestyle with a “coaching” approach. While it is true that families should manage their own medical records and data, providers should take the lead. Combining live interactions and virtual online coaches as needed, the exchange and use of data will bring significant and actionable insights that are applicable in the daily lives of individuals everywhere.

Taking it one step further, healthy lifestyles within various segments of the population can be promoted by developing and implementing community wide initiatives that leverage vital data monitoring. These efforts can impact greater health issues such as diabetes, blood pressure, early child birth, obesity and other conditions. By adopting a consistent and motivating approach toward shared data exchange processes, providers will be able to better manage and motivate patients, while driving positive, ongoing change at the fraction of the cost of live interactions.

In healthcare, proper use of medical data is critical to optimizing outcomes and lowering costs, but the absence of a truly collaborative effort among patients and providers remains as a barrier to success.

Drivers of Change

is the fact that no simple solution is available and no national initiative – legislative or otherwise – exists to helps fill this engagement void in healthcare. Just as providers are responsible for patient care and satisfaction, so too should they serve as facilitators of patient engagement. By taking this approach, new age health initiatives will reshape the culture of healthcare and lead the industry to a truly preventative system.

A municipal hospital system’s Epic EMR install has gone dramatically south over the past two years, with four top officials being forced out and a budget which has more than doubled.

In early 2013, New York City-based Health and Hospitals Corp. announced that it had signed a $302 million EMR contract with Epic. The system said that it planned to implement the Epic EMR at 11 HHC hospitals, four long term care facilities, six diagnostic treatment centers and more than 70 community-based clinics.

The 15-year contract, which was set to be covered by federal funding, was supposed to cover everything from soup to nuts, including software and database licenses, professional services, testing and technical training, software maintenance, and database support and upgrades.

Fast forward to the present, and the project has plunged into crisis. The budget has expanded to $764 million, and HHC’s CTO, CIO, the CIO’s interim deputy and the project’s head of training have been given the axe amidst charges of improper billing. Seven consultants — earning between $150 and $185 an hour — have also been kicked off of the payroll.

With HHC missing so many top leaders, the system has brought in a consulting firm to stabilize the Epic effort. Washington, DC-based Clinovations, which brought in an interim CMIO, CIO and other top managers to HHC, now has a $4 million, 15-month contract to provide project management.

The Epic launch date for the first two hospitals in the network was originally set for November 2014 but has been moved up to April 2016, according to the New York Post. HHC leaders say that the full Epic launch should take place in 2018 if all now goes as planned. The final price tag for the system could end up being as high as $1.4 billion, the newspaper reports.

So how did the massive Epic install effort go astray? According to an audit by the city’s Technology Development Corp., the project has been horribly mismanaged. “At one point, there were 14 project managers — but there was no leadership,” the audit report said.

The HHC consultants didn’t help much either, according to an employee who spoke to the Post. The employee said that the consultants racked up travel, hotels and other expenses to train their own employees before they began training HHC staff.

HHC is now telling the public that things will be much better going forward. Spokeswoman Ana Marengo said that the chain has adopted a new oversight and governance structure that will prevent the implementation from falling apart again.”We terminated consultants, appointed new leadership, and adopted new timekeeping tools that will help strengthen the management of this project,” Marengo told the newspaper.

What I’d like to know is just what items in the budget expanded so much that a $300-odd million all-in contract turned into a $1B+ debacle. While nobody in the Post articles has suggested that Epic is at fault in any of this, it seems to me that it’s worth investigating whether the vendor managed to jack up its fees beyond the scope of the initial agreement. For example, if HHC was forced to pay for more Epic support than it had originally expected it wouldn’t come cheap. Then again, maybe the extra costs mostly come from paying for people with Epic experience. Epic has driven up the price of these people by not opening up the Epic certification opportunities.

On the surface, though, this appears to be a high-profile example of a very challenging IT project that went bad in a hurry. And the fact that city politics are part of the mix can’t have been helpful. What happened to HHC could conceivably happen to private health systems, but the massive budget overrun and billing questions have government stamped all over them. Regardless, for New York City patients’ sake I hope HHC gets the implementation right from here on in.

The Centers for Medicare & Medicaid Services (CMS) continues gearing up for the October 1 ICD-10 compliance deadline with Acting Administrator Andy Slavitt scheduled to address the ICD-10 transition during a national provider call later this month.

On August 27, Slavitt will provide a national implementation update as the nation reaches the five-week countdown to October 1. Also scheduled to speak are American Health Information Management Association (AHIMA) Senior Director of Coding Policy and Compliance Sue Bowman and American Hospital Association (AHA) Director of Coding and Classification Nelly Leon-Chisen.

Two recent surveys show industry-wide progress toward a successful ICD-10 transition in October. In July, the 2015 ICD-10 Readiness reportpublished by AHIMA and the eHealth Initiative stated that half of respondents had completed test transactions with payers or claims clearinghouses.

Despite these positive findings, the report also revealed that ICD-10 preparation gaps still remain for many providers in the area of testing and revenue impact assessments. Only 17 percent indicated that they had completed all external testing. Similarly, only a minority of respondents (23%) have contingency plans related to ICD-10 go-live.

More recently, latest ICD-10 readiness survey from the Workgroup for Electronic Data Interchange (WEDI) showed physician practices to be lagging behind their counterparts.

As compared to seven-eighths of hospitals and health systems ready for October 1, less than a half of physician practices indicated they would be ready. This disparity was also evident in the area of provider impact assessments. Only one-sixth of physician practices had undertaken the assessment versus three-fifths of hospitals and health systems. "This lack of progress is cause for concern as it will leave little time for remediation and testing," WEDI reported.

In a letter to Department of Health & Human Services Secretary Sylvia Mathews Burwell, WEDI cautioned that without a concerted effort the ICD-10 transition could lead to negative consequences for the healthcare industry.

"We assert that if the industry, and in particular physician practices, do not make a dedicated and aggressive effort to complete their implementation activities in the time remaining, there is likely to be disruption to industry claims processing on Oct 1, 2015," the organization stated.

Around the same time, CMS provided clarification about ICD-10 flexibilities it make available to providers following a joint statement with the American Medical Association (AMA) in June. The major ICD-10 flexibility is the federal agency's decision not to reject claims coded incorrectly in ICD-10.

"Medicare claims with a date of service on or after October 1, 2015, will be rejected if they do not contain a valid ICD-10 code," the federal agency stated. "The Medicare claims processing systems do not have the capability to accept ICD-9 codes for dates of service after September 30, 2015 or accept claims that contain both ICD-9 and ICD-10 codes for any dates of service. Submitters should follow existing procedures for correcting and resubmitting rejected claims."

Here's a quick look at the agenda for the MLN Connects Call:

National implementation update, CMS Acting Administrator Andy Slavitt

Coding guidance, AHA and AHIMA

How to get answers to coding questions

Claims that span the implementation date

Results from acknowledgement and end-to-end testing weeks

Provider resources

As the entire healthcare industry counts down to October 1, CMS appears ready to ramp up its activities.

I have been going to my family practitioner for years. During these visits I have been able to witness the devolution of the EMR. One thing I really enjoyed about him when we first met was how excited he was about his home grown EMR. He navigated quickly through it and dictated his notes. Then a few years later his affiliated hospital decided to standardize on an EMR. He had to give up his system and adopt to a new one. It was not ideal, and he would tell me all about his challenges, but he was able to use dictation and he completed his notes efficiently. Over time I noticed that his office fell into a nice routine and he could retrieve all the information he needed and dictate notes and orders quickly.

It had been a year since I had seen him and I called for an appointment. I had to provide all my information and none of my insurance information was in the system. You guessed it, they updated their practice management system and EMR. My patient experience went downhill from there. My previous clinical history was archived and not incorporated into the new EMR. So no trending, no real history. Years of electronic, discrete data now converted to a static view only. It is like having your EMR converted to paper, then scanned.

My provider was frazzled, I could tell the way he focused on my encounter and then had to “hunt and pick” his way around the new EMR. No microphone, no dictation, and no customized templates. He confided to me how the hospital system decided to migrate all their physicians to this new ASP platform and they all had to use the same templates. There was no dictation and even if he could, his old profiles were gone, meaning that he would have to retrain the system to recognize special words and speech patterns. Something that he had spent years investing in. Here he was working for a large healthcare organization and they would not use time proven physician adoption strategies. Instead they adopted physicians into whatever their leadership felt was needed.

My scenario is being played out through many healthcare organizations. EMR’s are being replaced because of vendor problems, healthcare acquisitions or just because they have outgrown the capabilities of the existing systems. So why are CIO’s allowing their organizations to use a “slash and burn” technique for system replacement? An even more alarming question is; why are CMIO’s not making a stand against it?

During the sales process EHR vendors focus on their ability to quickly install and train employees on the new system. Organizational leadership views this as an opportunity to get this “information technology” project out of the way so they can move on to the next thing. They might even have this labeled as a Strategic Initiative, tied to bonuses for on time completion.

The thought of having to deal with all the physician requirements and pay for the process of converting all the old data into the new system, is too daunting. Especially when you have software vendors telling them how difficult and costly it will be. Keep in mind that they have a vested interest in getting the system installed as quickly as possible.

I am certainly not going to talk about physician adoption. This has been the topic of just about every HIMSS conference. It also has been at the core of every EMR adoption strategy. So why are we having to visit this again? Because:

Organizations are focused on project life cycles and fail to factor impact to productivity.

Hospital leaders often do not understand ambulatory practice operations.

Leadership incentives are designed to accomplish quick wins.

CEO’s still do not understand the value of discrete data.

As my family physician entered information into my problem list, medication history (which I had to bring with me from Walgreens for my visit) and reviewed my labs (toggling back and forth trying to find scanned images of my previous lab values) I started to get annoyed. Not at him, but at the hospital leadership that placed more importance on their performance appraisals and ignored the impact they would have on thousands of patients. My data which my healthcare provider and I built for years was now relegated to view only files which could now be printed like a pdf. I am sure on a macro level they could trend on the population as a whole, but I have to rebuild my record, history and trends all over again.

Hospitals focus on episodes of care. Billing is all about the bed stay and the admission timeframe. For ambulatory care it is a longitudinal record. It is all about establishing that long term relationship with the patient. Providers can go months or years without seeing a patient, but are expected to jump into the exam room with a smile, a look of recognition, and an understanding of the patient’s history without having to ask all the same questions all over again.

As an industry we need to do a better job at safeguarding our patient’s records in a way that will allow them to have seamless transitions from one system to the next. Converting data to static views is not only counterproductive, but borderline irresponsible. My personal physician was an EMR champion that loved the technology because of what he could do for his patients. At the end of the day, that’s how it should be for all of us.

Your practice could have all the latest and greatest technologies at its disposal, but that doesn't necessarily mean it's going to be the fastest, most efficient, or highest-quality care provider. The opposite could be true, in fact, if technology is not well incorporated into your practice after it is implemented.

Unfortunately, many practices are struggling with post-implementation challenges, according to our 2015 Technology Survey Sponsored by Kareo, the findings are based on responses from more than 1,100 readers. While most of the respondents said they are using an EHR for instance, they also said their productivity is suffering as a result; and while more than half said they have implemented a patient portal, they also said they are struggling to get patients to use it.

But it's not just using technology post-implementation that is raising problems for practices; it's also protecting information that is stored on those devices after implementing them. While many respondents said they are using mobile devices in their everyday work, for instance, few said their practice has established mobile device security rules.

Here's a look at these post-implementation technology challenges and others reflected in our survey findings, and advice from experts regarding how your practice can adapt.

CHALLENGE #1: POST-EHR PRODUCTIVITY DROP

Each year for the past four years, we asked survey respondents to identify their "most pressing information technology problem." In 2012, 2013, and 2014, the most common response among survey takers was "EHR adoption and implementation." This year, for the first time, "a drop in productivity due to our EHR," and a "lack of interoperability between EHRs," received the highest percentages of responses.

Let's address the productivity challenge first. Medical practice consultant Rosemarie Nelson says practices that are struggling to get back up-to-speed after implementing an EHR should first assess whether "reverse delegation" between the provider and nursing support staff is to blame. "What happens is once we have this EHR in place and people see that they can task or message somebody else in the practice, they suddenly start to maybe put the burden in a place it shouldn't be," says Nelson. "In the paper days ... the nurses would manage all the incoming correspondence for the physician; they would manage the phones, they would manage the fax machine; basically they were managing [the physician's] paper inbox. Now, with the EHR, suddenly everything just goes to the physician's inbox." To get delegation moving back in the proper direction, Nelson recommends practices modify how nurses screen materials coming into the EHR so that physicians only receive information that requires a physician's review. One option, Nelson says, might be to allow a nurse "surrogate" to manage the physician's inbox so that the materials are prescreened appropriately.

Jeffery Daigrepont, senior vice president of the Coker Group, a healthcare consulting firm, has similar guidance regarding EHR documentation."When we work with clients, if we see or observe a physician doing the vast majority of data entry, then usually that is a sign that the system was implemented incorrectly," he says. "You really want to design your work flow and processes in a way that minimizes the doctors' time to do the data entry part."

He says practices should consider modifying their EHR to better meet physicians' work flow needs and to create a more standardized work flow for common patient complaints. "... One thing that computers are really good at doing is remembering things," says Daigrepont. "So if you know that for every time you have a patient with this particular visit or diagnosis you are going to follow these five or six steps or action items and it's pretty consistent patient after patient after patient, a lot of times [improving productivity] comes down to spending a little bit of extra time to design your [EHR] around your work flow and around the physician's behavior."

Practices should also consider "add-on" tools, such as voice recognition software and shortcut and abbreviation tools, that may help physicians navigate the system more quickly, says Nelson. To identify time-saving tools, she recommends consulting your vendor and engaging with EHR user groups.

CHALLENGE #2: EHR INTEROPERABILITY ISSUES

As noted, another common post-EHR implementation challenge identified by survey respondents was "lack of interoperability between EHRs." For practices struggling in this area, particularly those struggling to meet the transition-of-care requirements in meaningful use due to difficulty exchanging information with other healthcare systems, Nelson advises stepping up communication with those other healthcare systems. Work with them to find a solution, or pool resources to find one.

"Some of that is just pushing your partners," says Nelson. "If it's a hospital [make sure] they get discharge summaries pushed to you; if it's a key referral, then every certified EHR has to have the ability to share what's called a CCD [Continuity of Care Document] or a CCR [Continuity of Care Record]," says Nelson. "That [CCD or CCR] has key elements in it, which is really all we need. We need to have the patient's problem list, we need to have their medication list, we need to have their allergy list, labs would be great ... Some practices may not realize that they could get this [CCR or CCD] from another practice, and/or they may not realize that they are getting it, so they treat it like a fax instead of learning how to import it into their system so they don't have to re-enter data."

Also, consider participating in the Direct Project initiative, which helps support simple electronic exchanges between practices and their healthcare partners, says Nelson.

CHALLENGE #3: A LACK OF PATIENT PORTAL ENGAGEMENT

It's not just EHRs that are raising problems for practices post-implementation. While 54 percent of our 2015 Technology Survey Sponsored by Kareo respondents said their practice has a patient portal (up from just 20 percent in 2011), many respondents indicated they are struggling to make the most of their portal's capabilities. Sixty-three percent, in fact, said that "getting patients to sign up/use the portal" was their biggest patient portal-related challenge.

For practices struggling in this area, Nelson recommends using "teachable moments" to promote the portal; for example, when physicians and staff are about to share information with patients, or when they plan to share information with patients. A nurse who is following up with a patient after the physician visit might say, "If you go to our website and register for the portal, you'll be informed when your lab results are ready and you'll be able to view them online."

To increase the likelihood patients will follow through with signing up for the portal, send a text message or e-mail with information on how to sign-up for the portal shortly after the patient visit, says Daigrepont. "If you just say, 'Hey go to the portal,' as the patient is leaving, by the time they get in their car they've already forgotten that information."

Also, make sure that the portal offers key features that patients value, such as the ability to:

• Request appointments;

• Get prescriptions renewed;

• Review test results; and

• Look at visit summaries from previous visits.

"We have to offer more on the portal to make it worthwhile for [patients] to come back," says Nelson. "It's just like any website that a physician or nurse would go to, if there isn't anything of value after the second time they go, they're not going to want to go a third time."

Finally, when promoting the portal to patients, reassure them that the portal is secure, says Daigrepont. "I think a lot of times people are reluctant, especially when it comes to their healthcare information to [sign up] if they are not very much reassured that their privacy will be protected."

CHALLENGE #4: MOBILE DEVICE SECURITY

EHRs and patient portals are not the only technologies practices and physicians are implementing. More are also using mobile devices, such as smartphones and laptops, to store and share protected health information (PHI) and to communicate with patients. Sixty-seven percent of our survey respondents said they use mobile communication devices in the performance of their job.

While mobile devices streamline communication, they also raise potential security problems. In fact, the majority of HIPAA breaches occur due to lost or stolen mobile devices. Yet many practices are failing to take the proper precautions to secure the data stored on mobile devices, particularly when it comes to the use of personal mobile devices for work purposes. Only 32 percent of our survey respondents said they have implemented rules regarding this use of technology.

If your physicians and staff are using mobile devices for professional use, Nelson recommends:

• Requiring all devices to be password protected (and requiring those passwords to be changed every few months);

• Prohibiting staff from downloading PHI to mobile devices;

• Working with vendors to put safeguards in place that prevent staff from downloading PHI to their devices (staff and physicians may be able to view information remotely, but not download it); and

• Encrypting PHI so that the information stored on mobile devices is protected.

Practices should also inform physicians and staff that, in the event of a potential HIPAA breach, the practice may need to access the device, disable it, remotely wipe it, and so on, says Daigrepont. "I think as business owners you just have to be upfront with your employees," he says. "Say, 'We're happy to give you the convenience of using your personal device, but there's a little bit of a trade-off and here's what you need to know.'"

To ensure all staff and physicians are on board with your mobile device security rules, consider requiring them to sign a mobile device security agreement.

CHALLENGE #5: OVERALL TECH SECURITY

The increasing use of mobile devices for work-related purposes is not the only new technology that is raising security problems for practices. When acquiring a new piece of technology, whether it is an EHR, patient portal, or mobile device, the practice needs to assess how the use of that technology might raise security risks, and act accordingly to address and reduce those risks.

One of the best ways to do this is by conducting a security risk analysis, during which practices analyze the potential risks and vulnerabilities to the confidentiality, integrity, and availability of their electronic PHI.

Despite the fact that conducting a risk analysis is required under both HIPAA and meaningful use,only 36 percent of our survey respondents said they have conducted one.

That's a troubling statistic, says Michelle Caswell, senior director, legal and compliance, at healthcare risk-management consulting firm Clearwater Compliance, LLC. "We really try to get organizations to not think of the risk analysis as this sort of draconian regulation that [HHS'] Office of Civil Rights (OCR) is putting down on them," says Caswell, who formerly worked at the OCR. "We always say that if you do not conduct a risk analysis, you do not know what risks there are to your organization."

IN SUMMARY

Practices have rapidly implemented new technologies over the past few years, but that is only half the battle when it comes to using that technology effectively. Here are some of the common post-implementation challenges practices face:

In a surprise concession, the Centers for Medicare & Medicaid Services announced Monday that it would work with the American Medical Association on four steps designed to ease the transition to ICD-10.

Despite longtime disagreements on the topic, CMS will now adopt suggestions made by none other than the AMA with regard to the code set conversion. Those changes concern:

1. Claims denials. "While diagnosis coding to the correct level of specificity is the goal for all claims, for 12 months after ICD-10 implementation, Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family," CMS officials wrote in a guidance document.

2. Quality reporting and other penalties. "For all quality reporting completed for program year 2015 Medicare clinical quality data review contractors will not subject physicians or other Eligible Professionals (EP) to the Physician Quality Reporting System (PQRS), Value Based Modifier (VBM), or Meaningful Use 2 (MU) penalty during primary source verification or auditing related to the additional specificity of the ICD-10 diagnosis code, as long as the physician/EP used a code from the correct family of codes," CMS explained. "Furthermore, an EP will not be subjected to a penalty if CMS experiences difficulty calculating the quality scores for PQRS, VBM, or MU due to the transition to ICD-10 codes."

3. Payment disruptions. “If Medicare contractors are unable to process claims as a result of problems with ICD-10, CMS will authorize advance payments to physicians,” AMA president Steven Stack, MD, noted in a viewpoint piece on the group’s website.

4. Navigating transition problems. CMS intends to create a communication center of sorts, including an ICD-10 Ombudsman, "to help receive and triage physician and provider issues." The center will also "identify and initiate"resolution of issues caused by the new code sets, officials added.

"These provisions are a culmination of vigorous efforts to convince the agency of the need for a transition period to avoid financial disruptions during this time of tremendous change," wrote Stack.

While AMA played a pivotal role in bringing about these CMS concessions, it was not the only party calling for a smoother conversion to the new code set.

Some members of the U.S. Congress have publicly suggested a dual-coding conversion period wherein CMS would accept and process claims in both ICD-9 and ICD-10. Instead of dual coding, CMS indicated that "a valid ICD-10 code will be required on all claims starting Oct. 1, 2015."

So as things stand today, providers have to use ICD-10 come October – but CMS will be more flexible about denials and payments than it has previously suggested it would be.

The Medicare and Medicaid EHR Incentive Programs were established to improve the quality of care, boost population health management initiatives, and reduce overall healthcare costs, which is known as the Triple Aim of Healthcare. With these goals in mind, it is important to track the progress of meaningful use requirements and EHR incentive payments throughout the healthcare industry.

The Office of the Inspector General (OIG) found a major flaw in the EHR incentive payments completed by the Arkansas Department of Human Services. A total of 14 hospitals received incorrect EHR incentive payments, which resulted in an overpayment of $1.2 million.

An OIG report states that the organization looked at EHR incentive payments among 20 of the highest paid hospitals from November 1, 2011 to June 30, 2013. It was found that the Arkansas Department of Human Services paid 20 hospitals more than $19 million, which covered 65 percent of the total amount paid between the time period of the audit.

“The State agency did not always pay EHR incentive program payments in accordance with Federal and State requirements,” the report stated. “The State agency made incorrect EHR incentive payments to 14 hospitals. Specifically, for 13 hospitals, the State agency made incorrect payments totaling $1,225,734.”

The Arkansas Department of Human Services caused these errors because the agency had foregone following federal requirements with regard to cost report data elements concerning EHR incentive payments. Additionally, the organization failed to review supporting documentation for figures available in the reports.

The OIG recommends several measures that the Arkansas Department of Human Services will need to follow. First, it is important to refund $79,428 to the federal government. Also, the agency will need to modify the EHR incentive payments across the hospitals that received incorrectly calculated disbursement.

Additionally, it is suggested that the Arkansas Department of Human Services review all payment calculations given to hospitals that were not part of the 20 hospitals within the audit. The organization will need to determine whether payment adjustments are needed.

“The State agency did not concur with the recommendation to refund the net overpayment of $79,428 but stated that the incentive payments for 8 of the 13 hospitals had already been adjusted in accordance with our finding,” the report states. “The State agency also stated that it expected the incentive payments for the other five hospitals to be adjusted in accordance with our findings. The State agency also did not concur with our recommendation to work with the one hospital for which the total incentive amount was set aside to recalculate the incentive payment using the June 2009 cost report data.”

The Office of the Inspector General plays a major role in ensuring that various medical organizations are sticking to federal and state mandates. Hospitals and other providers attesting to meaningful use requirements under the EHR Incentive Programs will also need to ensure all information submitted to federal and state agencies are accurate in order to receive EHR incentive payments.

"They assume everything is plug-and-play, then panic when things go wrong. They set unrealistic timelines that demoralize staff. They rely too much on vendors. And they expect technology to somehow electronically solve complex human and managerial issues."

Leapfrog offers hospitals a test to assess the efficacy of their order entry systems, for instance, she notes.

One-third of the orders tested each year at more than 1,000 hospitals "don’t properly alert to errors," Binder writes. "Worse, one in six of the orders we test that would have killed the patients don’t get stopped by the systems."

On June 24, Doug Fridsma, M.D., Ph.D., in a presentation to the AMDIS Physician-Computer Connection Symposium being held at the Ojai Valley Inn and Spa in Ojai, Calif., shared with CMIO attendees some of the latest activity going on with regard to the American Medical Informatics Association (AMIA), the association of which Fridsma became president and CEO last fall, after having served as chief science officer in the Office of the National Coordinator for Health IT.

As part of the opening of that report, published online on May 29 in the Journal of AMIA (JAMIA), notes, “Over the last five years, stimulated by the changing healthcare environment and the HITECH Meaningful Use (MU) EHR Incentive program, EHR adoption has grown remarkably, and there is early evidence of benefits in safety and quality as a result. However, with this broad adoption many clinicians are voicing concerns that EHR use has had unintended clinical consequences, including reduced time for patient-clinician interaction, transferred new and burdensome data entry tasks to front-line clinicians, and lengthened workdays.” Further, the report’s introduction stated that “Interoperability between different EHR systems has languished despite large efforts. These frustrations are contributing to a decreased satisfaction with professional work life. In professional journals, press reports, on wards and in clinics, we have heard of the difficulties that the transition to EHRs has created.”

With regard to the way forward, the authors of the report said in their introduction, “Ultimately, our goal is to create a robust, integrated, inter-operable health system that includes patients, physician practices, public health and population management, and support for clinical and basic sciences research. EHRs are an important part of this ecosystem, along with many other clinical systems, but future ways in which information is transformed into knowledge will likely require all parts of the ecosystem working together. This ecosystem has been referred to as the ‘learning health system.’”

What’s more, the report’s authors noted, “Potentially every patient encounter could present an opportunity for patients and clinicians alike to contribute to our understanding of health care and participate in research and clinical trials. As part of the learning health system, EHRs have long been touted as beneficial to the safety and quality of health care, and studies have shown potential benefits related to information accessibility, decision support, medication safety, test result management, and many other areas. However, implementation of any new technology leads to new risks and unintended consequences; these too have been well documented.”

Speaking of the release of “EHR 2020,” Fridsma told the AMDIS audience on Wednesday that Senator Lamar Alexander, chair of the Senate HELP Committee, “was running around at Vanderbilt, saying, ‘This is something that addresses a lot of the concerns we have.’”

Fridsma noted in his comments that the effort that led to the “EHR 2020” report predated his tenure at AMIA, but reflects the broad focus of the association at this point in time. “We brought together experts to say, what will the EHR look like in the next few years, and what kinds of things could we discuss? And then the Senat HELP Committee testimony that occurred ten days after this was done” created results. “Lamar Alexander took the five principles and said, ‘I’m going to have five hearings on those principles.’” And that, Fridsma said, is what is expected to happen.

Fridsma summarized the learnings shared in the report by noting four main areas of focus. “The first thing we had in the report,” he said, “was that we need to simplify documentation. We went through a series of discussions on why documentation is so complex. We are accelerating to the next stage, but we’re not necessarily getting to the end goal. So we create a whole series of activities” around physician documentation, as a health system, he said, “one set around what is required by regulation, and the other necessary for patient care. Some of this is tied to how our reimbursement works. But the most important development at ONC was the CMS [Centers for Medicare & Medicaid Services] targets for alternative payment models, because that gives physicians and other providers financial incentives to move forward in this area. That will be more of an incentive than Stage 3 of meaningful use, which was really front-loaded.”

The other areas of focus of the report were the need to make regulation more focused; the need to increase transparency around EHR functions; and the need to encourage innovation. As for encouraging innovation, Fridsma told his audience, “That really speaks to a lot of the work going on at ONC right now around FHIR, etc. We’re moving from document-centered ways of viewing information to data-centered ways of viewing information. The EHRs we are using today are not the EHRs that the people we are training today are going to be using. And the way we’ll get there is to encourage APIs and other solutions.”

And he added that, with regard to the report, “We said, if you’re going to focus regulation and increase transparency and encourage attempts to simplify documentation, make sure to keep your patient at the center, as the North Star.” He added that “Our plan is to pick themes like these over the next year, and to focus on those themes” at AMIA, in a strategic way intended to help guide healthcare industry thinking on EHR development and evolution.

In the national discourse about interoperability, much of the focus is on enabling a doctor using one electronic health record to access patient information residing in a different hospital’s EHR, even when another vendor built it.

But is that really the best way to give doctors the data they need?

"Having the government mandate interoperability is completely wrong," JaeLynn Williams, president of 3M Health Information Systems, told me. "I think we should let the market drive it – and the market says physicians want a single workflow."

That workflow does not have to be directly in an electronic health record, either, and in all likelihood it won't be as the industry moves beyond its initial digitization and into what many are hailing as the post-EHR era, wherein new platforms come to market that enable clinicians to more effectively follow their patients.

If you picture the EHR as one piece of a software stack, rather than the entire application, these technologies are a layer of abstraction above the EHR and essentially reach down to get that data.

I'm going to group a bunch of tools together, for simplicity's sake, and christen them as part of a new breed of software delivering that patient data.

Practice Unite and 3M, with its workflow tools, are in there. Others include par8o, with its boldly-marketed "operating system for the entire healthcare industry," ExamMed's newly-minted "universal healthcare technology platform" and the TapCloud smartphone app, which the company calls "a powerful overlay to an EHR."

Overlay. That's the operative word and, indeed, while ExamMed and par8o are more about reaching and tracking patients they also, for lack of a better term, overlay EHRs and other software systems.

It's important to explain that, rather than being direct competitors, these vendors are a representation of emerging technologies that more closely tie clinicians with patients in a way where all parties have access to relevant data. Hospitals could implement and use two or more of them. And they are just a few of the countless innovators coming to market.

Make no mistake: None of these are going to take over the world and solve today's existing interoperability issues alone. Instead, what they have the potential to do is create pockets of interoperability that might not get us to the Holy Grail of any doctor being able to see all the records of any patient – but might land us somewhere close enough.

Take par8o, for instance. Lancaster Regional Medical Center is using the platform on top of multiple vendors' EHRs from triage to tracking patients' next steps in care outside its own facilities, according to Lancaster Regional CEO Russell Baxley, to essentially tie together various providers in the area with specialists, patients and payers. Other par8o customers such as MGM Resorts and Mt. Sinai in New York also have the potential to enable wide regions of information interoperability.

An industry misguided?

The Office of the National Coordinator for Health IT is at the epicenter of all this. Its 10-year roadmap to interoperability ambitiously aims for the end point of a learning health system – which is, in my opinion, a noble goal and one worthy of the federal government's efforts.

But not everyone will agree with me on that, of course. When I asked Williams if she thinks that the government should back off its efforts to drive standards that fuel interoperability, she cut to the chase: "I would say 'yes.' We're relying too much on standards."

Baxley didn't pull punches either.

"I think we played it out all wrong to get to where we need to be. There's nothing pushing anybody toward true interoperability," he said. "The incentives and the penalties are placed on the wrong people. The only way we'll have true interoperability is when the penalties are placed on the EHR providers and bonuses offered for those vendors to make their systems interoperable."

Inching closer

This new crop of platforms won't supplant ONC's work, of course, but they could soar right on by.

"The ability to capture data selectively and share it opportunistically in ways that empower the clinician will surpass any plans to create huge data warehouses and EHR-to-EHR interoperability," predicted par8o co-founder Adam Sharp, MD.

Indeed, as more and more pockets of interoperability expand outward, we inch ever closer to that broad-accessibility of data that so-called interoperability promises. But will that be close enough to nationwide interoperability to affect the care delivery improvements we all want?

"I think regions are good enough," 3M's Williams said. "We have pieces of interoperability that exist right now. I believe that we are a lot closer than we think."

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